Endoscopic implant system and method

ABSTRACT

Disclosed is a system for endoscopically implanting a medical implant, including an anchor, within a body cavity such as adjacent the gastroesophageal junction in a human stomach. The system includes one or more anchors positionable within one or more openings formed in tissue within the body cavity, such as cutouts formed in plicated body tissue. Tools are disclosed for positioning the anchors within the openings, and for coupling a food restrictor to the anchors.

PRIORITY

This is application is a divisional of U.S. Ser. No. 12/175,242 filedJul. 17, 2008, which claims priority to U.S. Provisional Application No.60/950,584, filed Jul. 18, 2007, and U.S. Provisional Application No.61/042,862, filed Apr. 7, 2008.

TECHNICAL FIELD OF THE INVENTION

The present invention relates to the field of systems for use inendoscopically implanting devices within the gastrointestinal system.

BACKGROUND

An anatomical view of a human stomach S and associated features is shownin FIG. 1. The esophagus E delivers food from the mouth to the proximalportion of the stomach S. The z-line or gastro-esophageal junction Z isthe irregularly-shaped border between the thin tissue of the esophagusand the thicker tissue of the stomach wall. The gastro-esophagealjunction region G is the region encompassing the distal portion of theesophagus E, the z-line, and the proximal portion of the stomach S.

Stomach S includes a fundus F at its proximal end and an antrum A at itsdistal end. Antrum A feeds into the pylorus P which attaches to theduodenum D, the proximal region of the small intestine. Within thepylorus P is a sphincter that prevents backflow of food from theduodenum D into the stomach. The middle region of the small intestine,positioned distally of the duodenum D, is the jejunum J.

Several prior applications, including U.S. Publication No. U.S.2007/0276432 having a priority date of Oct. 8, 2004 and U.S. PublicationNo. U.S. 2008/0065122, filed May 23, 2006 describe methods according towhich medical implants are coupled to tissue structures, such asplications or folds, formed within the stomach. Examples of methods anddevices for forming such tissue structures are described in U.S.Publication No. U.S. 2007/0219571 (entitled ENDOSCOPIC PLICATION DEVICESAND METHOD), filed Oct. 3, 2006, U.S. application Ser. No. 11/900,757(entitled ENDOSCOPIC PLICATION DEVICE AND METHOD), filed Sep. 13, 2007,and U.S. application Ser. No. 12/050,169 (entitled ENDOSCOPIC STAPLINGDEVICES AND METHODS), filed Mar. 18, 2008. Each of the referencedpublications and applications is incorporated herein by reference.

As disclosed in these prior applications, more robust and long lastingcoupling between the implant and the surrounding stomach wall tissue isachieved when the plications/folds are formed by retaining regions ofserosal tissue (i.e., the tissue on the exterior surface of the stomach)in contact with one another. Over time, adhesions form between theopposed serosal layers. These adhesions help to create strong bonds thatcan facilitate retention of the plication/fold over extended durations,despite the forces imparted on them by stomach movement and implanteddevices

Several of the disclosed methods for forming tissue plications include astep in which a hole or cut is formed in the plication, using theplication device or other devices. An example of this type of plicationis shown in FIG. 2A. This application discloses a system for attaching amedical implant to cutouts of this type, or to other types of openingsin the plications (e.g., cuts, slits, perforations, tissue tunnels,etc.).

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a schematic illustration of a human stomach and a portion ofthe small intestine.

FIG. 2A is a partial section of a stomach wall showing a stomach wallplication having an opening formed in it.

FIG. 2B is a cross-section view taken along the plane designated 2B-2Bin FIG. 1, and illustrating five plications formed in agastro-esophageal junction region of the stomach.

FIG. 3 shows an endoscopic implant system.

FIG. 4A is a perspective view of the anchor of the implant system ofFIG. 3.

FIG. 4B is a perspective view of the anchor of FIG. 4A, showing the headseparated from the stem.

FIGS. 5, 6, and 7 are partial section views of a human stomachschematically illustrating the anchor of FIG. 4A positioned in anopening in a stomach wall plication.

FIG. 8A is a perspective view of an anchor hand-off tool.

FIGS. 8B, 8C, and 8D are perspective views showing the anchor coupled tothe anchor hand-off tool.

FIG. 9A is a side elevation view of an anchor grasper in the openposition.

FIG, 9B shows the distal end of the anchor grasper of FIG. 9A in theclosed position.

FIG. 10A is a top plan view of the anchor grasper of FIG. 9A.

FIG. 10B is a cross-section view taken along the plane designated10B-10B in FIG. 10A.

FIGS. 11A and 11B are side elevation views of the distal end of analternative anchor grasper.

FIG. 12A shows a top perspective view of a first embodiment of arestrictor.

FIG. 12B shows a side perspective view of a second embodiment of arestrictor.

FIG. 12C shows a top perspective view of a third embodiment of arestrictor.

FIG. 13 shows a top perspective view of a fourth embodiment of arestrictor.

FIG. 14A shows a side perspective view of a fifth embodiment of arestrictor.

FIG. 14B is a perspective view of the embodiment of FIG. 14A, showingonly the rib structure.

FIG. 15A is a side elevation view of a restrictor guide.

FIG. 15B is a cross-section view of the restrictor guide taken along theplane designated 15B-15B in FIG. 15A.

FIG. 16A is a perspective view of the distal portion of the restrictorguide, showing the mount in the open configuration.

FIG. 16B is similar to FIG. 16A and shows the mount in the closedconfiguration.

FIG. 16C is a cross-section view of the mount in the open configuration.

FIG. 17A is a perspective view of a restrictor, showing the restrictorpositioned on the restrictor guide, with the mount in the openconfiguration.

FIG, 17B is similar to FIG. 17A but shows the mount in the closedconfiguration.

FIG. 17C is a perspective showing the interior of a restrictorpositioned on the restrictor guide.

FIG. 18A is a perspective view showing the proximal end of therestrictor guide.

FIG. 18B is a perspective view showing the distal portion of themulti-lumen portion of the restrictor guide.

FIGS. 19A and 19B schematically illustrate elements of the systempositioned in the stomach in preparation for transferring an anchor froman anchor hand-off to the anchor grasper that will then draw the anchorthrough the opening in the plication.

FIGS. 20A, 20B, 20C, 20D, 20E, and 20F schematically illustrate transferof the anchor from the anchor hand-off to the anchor grasper within thestomach.

FIGS. 21A and 21B are perspective views showing the anchor grasperengaging different portions of the anchor head.

FIGS. 22A, 22B, and 22C schematically illustrate a plurality of anchorsthat have been placed in plications in the stomach, together withelements of the disclosed system,

FIG. 23 is a perspective view of the proximal end of the endogastrictube, showing use of the tool organizer.

FIG. 24A is a perspective view of a restrictor being advanced ontoproximal ends of a collection of anchor graspers.

FIG. 24B is a perspective view similar to FIG. 24A showing therestrictor advanced further along the anchor graspers.

FIG. 25A is a schematic illustration showing the downstream side of arestrictor within the stomach, anchored to plications using anchors.

FIG. 25B is a schematic illustration showing the upstream side of arestrictor within the stomach, anchored to plications using anchors.

FIGS. 26A, 26B, 26C, and 26D schematically illustrate use of theplicator for forming tissue plications and for forming holes in theplicated tissue.

DETAILED DESCRIPTION

FIG. 2B is a schematic cross-section view of the stomach, lookingdistally into the stomach interior. In this view, five tissue plicationsP having openings such as cutouts C are shown to have been formed in thestomach wall tissue. This view would seem to illustrate clear access viathe esophagus to the plications and cutouts using endoscopicinstruments. However, the natural undulations and folds of the actualstomach tissue, and the constant movement of the stomach, limit thevisibility of the cutouts and even the plications themselves, renderingit difficult to endoscopically access the cutouts in an actual humansubject. The disclosed system facilitates access to the cutouts, andprovides for an efficient method for coupling an implant to the cutouts.

FIG. 3 illustrates an embodiment of an endoscopic implant system 10 thatmay be used for this purpose. In general, system 10 includes multipleanchors 12 (one shown) that are implanted in the cutouts and an implant14 to be coupled to the anchors 12. The implant can be any type ofimplant to be anchored within the stomach. In the disclosed embodiment,the implant is a restrictor 14 designed to slow the rate at which foodcan enter the stomach from the esophagus.

An anchor hand-off 16 delivers the anchors into the stomach, and anchorgraspers 18 (one shown) are used to position the anchors within thetissue openings and also to guide the restrictor 14 to the implantedanchors. A restrictor guide 20 is provided for advancing the restrictorinto position in the stomach. An endogastric overtube 22 is provided forestablishing a working channel between the mouth and the stomach. Othertools shown elsewhere in the drawings, such as a multi-lumen guide 24(FIG. 19A), articulated guides 25 (FIG. 19A), and one or more endoscopes26 (FIG. 19A) are additionally provided.

Anchor

One embodiment of an anchor 12 is shown in FIG. 4. A preferred anchorwill pass though the opening C in the plication cutout with relativeease and minimal tissue trauma, but will resist pulling out of theopening in the cutout when subjected to the stresses imparted to it bythe restrictor. Moreover, a preferred anchor will minimize the stressand strain on the stomach wall and distribute a given stress as evenlyas possible so as to prevent the stomach's natural defense from engagingin an attempt to eliminate the anchors and restrictor.

Referring to FIG. 4A, the general features of the anchor 12 include abase 28, a stem 30, and a head 32. The anchor is formed using materialsthat are durable within the stomach environment. In one embodiment, thehead 32 is molded out of a higher durometer compliant material (such as50 shore A durometer Silicone) while the stem 30 and base 28 are moldedout of a softer compliant material (such as 5 shore A durometerSilicone). Since the loading on the anchor from the restrictor implantcan be seen as shear against the edges of the opening in the plication,the stern 30 is formed to have a relatively large diameter (2 mm-8 mm)to minimize stress and abrasion on the stomach wall tissue inside theopening. The edges of the anchor are molded with generous fillet radiito minimize abrasion of stomach wall tissue.

Head 32 includes a ring 34 and a plurality of struts 36 coupling thering 34 to the stem 30, and an elongate loop 38 extending from the ring34. The anchor is elastically deformable to an elongated shape (seeFIGS. 20D and 20E) in response to application of tension to the ring 34or loop 38 (collectively referred to as the “rim”). This allows theanchor to be drawn into a streamlined shape so that it can be drawnthrough the opening in the plication and also through an opening in therestrictor. When the anchor is pulled from the rim, its shape lengthensand slims down to fit through a much smaller hole. For example in oneembodiment, in its natural state the anchor has an outer head diameterof approximately 0.600 inch (15 mm), but in its streamlined orientationit can fit through a plication opening of 0.200 inch (5 mm). However,once implanted, the anchor's shape resists pull-out force to a higherdegree since the rim is not being pulled and lengthened directly. Alsoin this embodiment, the base is designed so it will not pull through thehole and may have an outer diameter of approximately 1 inch (25.4 mm)

Referring to the top view of the anchor 12 shown in FIG. 5, when ananchor is implanted in a plication opening, the anchor's proximity tothe wall of the stomach with its enveloping rugae can make it difficultto find and grab onto the anchor when it is time to couple therestrictor implant to the anchors. The head 32 is shaped to have anundulating profile to enhance its visibility and accessibility when theanchor is positioned in a plication opening. The undulation of the headforces several of the elements of the head away from the wall to makethem more visible and also to allow a grasping tool to latch onto one ofthose elements without also grabbing adjacent tissue.

Referring to FIG. 6, the base 28 is preferably formed to have anasymmetrical shape. In the illustrated example, one edge 40 of the baseis formed to have a flatter curvature than that of the other edge 42 ofthe base. When implanted, the anchor self-orients to position theflatter edge 40 against the adjacent stomach wall as shown. Since theloop 38 of the head extends in a direction opposite to the side of theanchor on which the flatter edge 40 is position, this self-alignmentcauses the loop 38 to extend towards the center of the stomach as shownin FIG. 7. This makes it easier to find segments of the anchor headamongst the folds of the stomach which can envelope other segments.

Referring again to FIG. 6, the base 28 preferably includes a relativelylarge surface area (e.g., approximately 1 square inch) so as todistribute the stress of holding the restrictive implant in place over alarge percentage of the surface area of the tissue plication.Reinforcing ribs 44 may be positioned on the underside of the base,radiating from the stem to the edges of the base, to facilitatedistribution of stress while minimizing the overall weight of the base.

Anchor Hand-Off Tool

Anchor hand-off 16 is an instrument used to deliver individual anchorsto the implantation site, and to hand-off each anchor to an anchorgrasper which pulls the anchor through an opening in a plication.

Referring to FIG. 8A, one embodiment of an anchor hand-off 18 includes atorqueable elongate shaft 46 having a wire element 48 extending from itsdistal end and attachable to an anchor.

In one embodiment, the anchor hand-off 16 has a horseshoe shaped formwith an opening 45 that narrows to form a constriction 47. Thestretchable nature of the anchor stem 30 allows it to be squeezedthrough the constriction 47 and thus held in place by friction. SeeFIGS. 8B-8D. Upon pulling on the head portion 32 by the anchor grasper,18, the stem 30 elongates and passes out of the horseshoe shapedconstriction.

Shaft 46 is slidably disposed in an articulating guide 49 that willarticulate in response to actuation using pull wires or other meansknown to those skilled in the art. The articulating guide 26 may be onewith video capability, for example it might be an articulatingendoscope. In one embodiment, wire element 48 is detachable from theshaft 46 of the anchor hand-off 16 to allow shaft 48 to pass through asmall diameter tool channel in the articulating guide 26. Once thedistal end of the shaft 46 reaches the distal end of the guide 26, thewire element 48 is coupled to the shaft 46.

Furthermore, the anchor hand-off tool 16 may be designed to hold theanchor behind (or axially off-set from) the distal tip of thearticulating guide 26 with video capability. This facilitates greatervisibility at the target site/plication by positioning the held anchorout of the endoscope's field of view as shown in FIGS. 8C and 8D. Toperform the actual hand-off of the anchor 12, the user can extend andtorque the hand-off tool 16 to position at least a portion of the anchorhead 32 within the field of view.

Anchor Grasper Tool

Anchor grasper 18 is designed to couple to or engage a portion of thehead 32 of an anchor 12. It is used to pull the anchor 12 through anopening in a plication, and to pull the anchor through a correspondingopening in a restrictor that is to be implanted. The anchor grasper 18may have a variety of designs that allow these functions to be carriedout. One such design is shown in FIGS. 9A and 9B an employs acoupling/grasping element 50 that takes the form of a hook 52 having agate 54 that closes against the opening in the hook 52. The hook andgate are naturally biased in the open position shown in FIG. 9A.

A closure tube 56 is longitudinally slidable over the hook and gate tolock them in the closed position, thus preventing them from separating.The collar and associated features are proportioned to ensure that whenthe grasping element 50 is to be locked, bending of the shaft of theanchor grasper 18 does not cause the closure tube 56 to slide into aposition that will release the grasping element 50 from the lockedposition.

Referring to FIG. 10B, the closure tube 56 is mounted to a torqueableelement 58 (preferably a coil), which in turn is coupled to outer tubing60. An L-shaped slot 62 is formed in the outer tubing 60. As best shownin FIG. 10A, slot 62 includes a longitudinal segment 63 a and apartially circumferential segment 63 b.

Hypotube 64 is slidably and rotatably disposed within outer tubing 60,and includes a pin 66 disposed within the slot 62. Hypotube 64 ismounted to a tapered handle 68. A cable 70 has a distal end coupled tothe grasping element 50 and a proximal end mounted to the handle 68.

To close and lock the grasping element, the outer tube 60 is advanceddistally relative to the handle 68. Advancement of the outer tube 60pushes the coil 58 and thus the closure tube 56 in a distal positionuntil the closure tube 56 moves the grasping element 50 to the closedposition shown in FIG. 9B. As the outer tube 60 moves distally,longitudinal segment 63 a of the slot 62 slides over pin 66. The outertube 60 is then rotated to cause positioning of pin 66 within thecircumferential segment 63 b of the slot 62, and to thereby lock theouter tube 60 in the distal position. To unlock the grasper element 50,the outer tube 60 is rotated in the opposite direction to release thepin 66 from the circumferential segment 63 b. Since the closure tube isno longer locked in the distal position, the grasping element 50 movesto the open position due to its natural bias, thereby pushing the outertube 60 in a proximal direction.

FIGS. 11A and 11B show an alternative grasper element 50 a which ismoved between open and closed positions using a system 72 of linkagespivoted using a longitudinally slidable push rod 74.

Restrictor

The restrictor is an implant designed to slow the passage of food fromthe esophagus into the stomach. The illustrated embodiments, therestrictor is positioned in the stomach such that food enters therestrictor through a proximal opening and exits the restrictor through adistal opening. The restrictor and/or openings are proportioned to slowthe rate at which food can move into or through the restrictor, and/orfrom the restrictor into the rest of the stomach.

A preferred restrictor is proportioned to be coupled to anchors thathave been coupled to plications in the gastroesophageal junction regionof the proximal stomach. In a preferred design, the restrictor 14includes features that minimize pulling against the anchors when therestrictor encounters stress as a result of food moving through therestrictor and/or movement of the stomach. Minimizing pulling at theanchors is beneficial for minimizing stress on the stomach wall tissuecoupled to the anchors. In general, the restrictor 14 is designed tohave compliance between the anchor points (i.e., the points at which theimplant is coupled to the tissue directly or using the anchors). Thiscompliance may be achieved using the geometry of the restrictor 14and/or using restrictor materials selected to give compliance betweenanchor points.

In a first embodiment shown in FIG. 12A, the restrictor 14 is a sleevehaving a wall and a plurality of anchor openings 80 formed in the wall.The restrictor wall is an undulating wall defining multiple folds 76that give it compliance even when molded from a relatively more stiffmaterial (such as 30 shore A silicone). When viewed from the side (seethe second embodiment 14 a in FIG. 12B), it can be seen that theproximal edge of the restrictor 14 undulates to define peaks 78 in theprofile of the proximal edge. When viewed from the top (FIG. 12A), itcan be seen that the circumferential profile of the restrictor alsoincludes peaks 82 extending radially outwardly. These peaks 82 definechutes 84 extending from the proximal peaks 78 towards a distal orifice86. When the restrictor is implanted, the chutes 84 help to channelingested material towards the distal orifice 86.

Anchor openings 80 are positioned between the radial peaks 82. Theseopenings may be positioned in the portion of the wall that is at themost radially inward position as on the restrictor 14 a of FIG. 12B, orthe undulations in the wall may be such that the openings 80 are in asection of wall that is positioned between some inwardly extending folds88 as in FIG. 12A (or that, in other words, forms smaller radial peaks90 than the radial peaks 82).

Openings 80 may be surrounded by reinforced sections 92 formed usingthicker regions of silicone, or a stronger material embedded in orattached to the silicone. Additional reinforcements such as ribs 94 a,94 b may extend from the openings 80 towards the orifice 86 and/or fromthe proximal peaks 78 towards the orifice 86 and may be formed usingsimilar techniques.

The edge of the wall defining the orifice 86 preferably includes foldsor undulations 96, allowing the orifice to be compliant as well. Inaddition, small holes 98 are arranged around the orifice to allow therestrictor 14 to be coupled to the restrictor guide used to deliver therestrictor into the stomach.

An alternative restrictor 14 b shown in FIG. 12C is similar to therestrictor of FIG. 12A, but is molded to be flat for ease ofmanufacturing, but assumes its undulating configuration at the foldswhen coupled to anchors at anchor openings 80.

Yet another alternative restrictor 14 c (FIG. 13) is molded out ofhighly compliant material (such as 40 shore 00 silicone) to put minimalstress on attached stomach tissue. This embodiment includes a reinforcedproximal rim 100.

An additional restrictor 14 d is molded out of a combination of high andlow compliance material (such as 50 shore A plus 40 shore 00 silicones)in different areas of the restrictor to achieve optimal performance. Arib structure 94 c (see FIG. 14B) out of stiffer material serves tomaintain the restrictor shape in the open position within the stomach.IN this example, rib structure 94 c includes an undulating ring 94 dencircling the orifice 86, and ribs 94 e extending to peaks 78. In thismanner, the rib structure 94 c maintains apposition of the restrictoragainst the wall of the stomach in order to improve the effectiveness ofcatching food, particularly in the chutes 84. In addition to the stifferrib structure, the assembled restrictor contains a very soft web 95 ofmaterial that forms the funnel shape and also serves to link togetherthe anchor points 80 (see FIG. 14A). The soft compliant nature of theweb material minimizes the stress to the plication tissue by allowingfull flexibility.

Restrictor Guide Tool

Restrictor guide 20 generally includes a tubular shaft 101, a distalportion comprising a coupling element/mount 102 and a proximal portion104.

In a preferred restrictor guide, the mount 102 is designed to supportthe restrictor 14 during delivery of the restrictor into the stomach andcoupling of the restrictor 12 to the stomach wall (directly or usinganchors or other means as disclosed herein). In the illustratedembodiment, mount 102 includes a collar 103 on the distal end of theshaft 101. A pair of tubes 112 extend distally between the collar 103and a ring 107. Ring 107 includes a plurality of distally extending pins106 and a central opening 109. A tube 111 is positioned co-axially withthe opening 109. A distal cap 108 is mounted to the distal end of thetube 111. Cap 108 includes an opening positioned in alignment with theopening of the ring 107 and the lumen of the tube 111. Bores 110 in thecap are positioned so that proximal advancement of the cap 108 relativeto the ring 107 causes pins 106 to enter the bores 110.

Referring to FIG. 17A, pins 106 are arranged to allow a user to couplethe restrictor 14 to the restrictor mount by threading the holes 98surrounding the orifice in the restrictor 14 over the pins 106 as shown.When the restrictor 14 is mounted in this way, the tube 111 is disposedin the orifice 86 of the restrictor, and the cap 108 is positioneddistal to the restrictor. Restrictor 14 is retained on the mount 102 bymoving the cap 108 in a proximal direction until bores 110 slide overthe pins 106, thus capturing the restrictor 14 between the cap 108 andthe ring 107 by preventing the restrictor from sliding off the pins. SeeFIG. 17B.

Drive rods 112 a (FIG. 16A) extend through the tubes 112 and are coupledat their distal ends to flanges 120 on the proximal end of tube 111. Theproximal ends of the drive rods 112 a are advanceable by an actuator atthe proximal end of the restrictor guide. Manipulation of the actuatorwill cause the drive rods 112 a to move distally relative to the tubes112, causing distal movement of the cap 108 relative to the ring 107. Inone current embodiment, rotation of a threaded nut on the proximalhandle moves a threaded piece inside the handle that is connected towires or cables that communicate with the drive rods 112 a. In anotherembodiment, the drive rods 112 a may be lead screws, and the actuatormay include a knob and associated gearing for rotating the lead screwssuch that they advance the cap 108 distally. Alternatively, the actuatormay include a spring that is initially locked in a compressed positionusing a latch. According to this embodiment, a button or other elementis manipulated by the user to disengage the latch, thus releasing thespring from the compressed position to drive the drive rods distally.Other alternatives include pneumatic or hydraulic actuation of the cap108. In other embodiments, the actuator may be a handle that allows theuser to manually advance the drive rods to advance the cap.

Proximal portion 104 of the restrictor guide 20 is a multi-lumen guidehaving a central lumen 114 through which the tubular shaft 101 extends,and a plurality of peripheral lumens 116 arranged around the centrallumen. The peripheral lumens 116 are proportioned to accommodate theanchor graspers 18. Each of the peripheral lumens 116 has a proximalport fitted with a seal (which may be, for example, a duck bill seal)that will seal around the shaft of a grasper 18 positioned in the lumen,and that will self-seal when the grasper 18 is removed from the lumen.

Exemplary Procedure

Use of the system 10 to implant a restrictor 14 will next be described.According to one embodiment, the method is performed following aninitial procedure in which a plurality of plications P having cutouts orother openings C are formed. In another embodiment, after each plicationis formed, an anchor 12 is implanted in that plication's opening for thedual purpose of marking the location of the plication as well asensuring that the opening does not close in the natural healing processof the tissue. The anchor implantation procedure may immediately precederestrictor implantation, or may instead be performed in advance of therestrictor implantation procedure to allow reinforcement of theplications through the body's healing process.

In the initial phase of the restrictor implantation procedure, anchors12 are positioned in the openings of the plications P. Referring to FIG.19A, the endogastric tube 22 is introduced into the mouth and throughthe esophagus, and parked with its distal opening in a portion of thestomach or esophagus that is proximal to the plications P. After eachplication with opening is created, a multi-lumen (or cannulation) guidetube 24 may be passed through the endogastric tube 22. Multi-lumen guidetube 24 may have a central lumen 24 a and peripheral lumen 24 b in asimilar arrangement to the lumen of the restrictor guide 20 (FIG. 18B).

Outside the body, an anchor hand-off 16 is passed through a tool channelof an endoscope 26 such that the anchor engaging wire 48 extends fromthe endoscope lumen. With the engaging wire in this position, an anchor12 is coupled to the engaging wire 48, and the endoscope 26, anchorhand-off 16, and anchor 12 are together passed through the central lumen24 a of the multi-lumen guide tube 24 and into the stomach as shown inFIGS. 19A and 19B. The endoscope 26 is retroflexed within the stomach toprovide visualization of the plication P.

Next, an articulating guide 25 is advanced through a peripheral lumen 24b of the multi-lumen guide tube 24 and into the stomach. An anchorgrasper 18 is positioned in the lumen of the guide 25. Undervisualization using endoscope 26 (with anchor hand-off 18 retracted sothat the anchor is out of view), guide 25 is articulated to orient thegrasper 18 towards the opening C in the plication, and the grasper 18 isthen advanced through the opening as also shown in FIGS. 19A and 19B.The grasping element 50 of the grasper 18 is moved into the openposition.

Referring to FIGS, 20A, 20B and 20C, anchor hand-off 16 is advancedfurther from the endoscope 26 until the head 32 of the anchor ispositioned within reach of the grasping element 50. Grasping element 50is manipulated to engage the head 32. While it is preferable to engagethe loop 38 as shown in FIG. 21A, the structure of the head 32 allowsfor engagement of other portions of the head such as the struts 36 asshown in FIG. 21B, or the ring surrounding the struts 36. Engagementbetween the anchor and the anchor grasper is secured by moving thegrasping element 50 into the locked position. Next, the anchor hand-offis retracted into the endoscope in order to separate it from the anchorgrasper. This action results in stretching the anchor stem and thuscausing it to release from the horseshoe shaped form. See FIG. 20D. Thehandle of the anchor grasper 18 is then withdrawn to pull the head 32 ofthe anchor through the opening C in the plication as in FIG. 20E. Asdiscussed above, application of tension to the head 32 causes the anchorto elongate to a narrow profile that will pass readily through theopening C in the plication. The jaws of the anchor grasper 18 are openedto release the anchor 12. FIG. 20F.

The endoscope 26 and anchor hand-off 16 are withdrawn from the guidetube 24 along with the multiple lumen guide and articulating guide.After another plication is created, the process is repeated for eachanchor that is to be implanted. See FIGS. 22A-22C.

As each anchor is implanted, its corresponding anchor grasper ispreferably left coupled to the ring of the anchor, although it mayinstead be withdrawn from the body. At the end of the anchor-positioningphase of the procedure, each anchor is positioned extending through aplication opening (FIG. 22A). If the anchor graspers were left in placecoupled to the rings of each anchor, the handles of each separate anchorgrasper 18 extend out of the body. Organization of the anchor graspers18 is maintained by the multi-lumen cannula 24.

If the anchor graspers 18 are not left in place following implantationof the individual anchors 12, the graspers 18 are re-coupled to theanchors prior to the restrictor-positioning phase. Specifically, each ofthe graspers 18 is reintroduced into the stomach and endoscopicallyguided by its corresponding articulated guide 25 into engagement withthe head 32 of one of the anchors. As discussed in the Anchors sectionabove, orientation of the loop 38 to extend in a direction opposite tothe asymmetrical base 28 helps to orient the loop 38 centrally withinthe stomach so that the loops 38 may be more easily seen and engaged bythe graspers 18.

The restrictor-positioning phase of implantation begins with each anchorthat is to be coupled to the restrictor having a separate anchor grasper18 coupled to it. If the multi-lumen guide 24 is still in use at thispoint, with individual ones of the graspers 18 in the peripheral lumen24 b, the guide 24 is withdrawn from the endogastric tube 22 and removedfrom the handles of the anchor graspers. The tapered proximal ends ofthe anchor graspers 18 allow the lumens 24 b of the guide 24 to passeasily over them. Before the multiple lumen guide is completely removedfrom the endogastric tube 22, the anchor grasper tool shafts are lockedinto a tool organizer 130 at the proximal end of the endogastric tube 22as shown in FIG. 23. Organizer 130 includes slots 132 positioned toreceive the shafts of the graspers 18, leaving them arranged around themain lumen 134 of the endogastric tube. This serves to maintain therelative clocking of each grasper at the proximal end to a correspondinganchor location at the distal end.

The restrictor 14 is prepared for implantation by threading anchoropenings 80 in the restrictor over the tapered proximal ends of theanchor graspers 18, which at this point are still extending out of theendogastric tube 22. FIG. 24A. The restrictor 14 is mounted to the mount102 of the restrictor guide 20 in the manner disclosed in the RestrictorGuide section above. This step may be performed before or after therestrictor is threaded over the anchor graspers.

Next, the restrictor guide 20 is advanced over the tapered proximal endsof the anchor graspers 18, which are still extending out of theendogastric tube 22. The restrictor guide 20 is positioned so that eachof its peripheral lumens 116 advances over a separate one of the anchorgraspers 18. FIG. 24B. Continued distal advancement of the guide 20advances the guide 20 and restrictor 14 through the endogastric tube 22and into the stomach.

In a final step, the anchors 12 are pulled through the anchor openings80 to couple the restrictor 14 to the anchors 12. In this step,distally-oriented pressure is applied to the restrictor guide 20 whilethe anchor graspers 18 are one-by-one pulled proximally, causing theanchors 12 to elongate sufficiently to pass through the openings 90.Coupling between each anchor and its corresponding opening 80 isconfirmed visually and/or by tactile feedback reflecting the “pop” ofthe anchor moving through the opening 80. Once the restrictor 14 hasbeen coupled to the anchors 12, the cap 108 of the restrictor guide 20is advanced distally to release the restrictor as described in theRestrictor Guide section above. The anchor graspers 18 are unlocked andseparated from the anchors. The restrictor guide 20, anchor graspers 18,guides, etc. are withdrawn from the body, leaving the restrictor 14 andanchors 12 in place as shown in FIGS. 25A and 25B.

The system of FIG. 3 may additionally include one or more tools for usein forming plications in the stomach wall tissue and for forming holesin the plicated tissue. Examples of such plicators are found in thefollowing co-pending U.S. patent applications: U.S. Publication No. U.S.2007/0219571 (entitled ENDOSCOPIC PLICATION DEVICES AND METHOD), filedOct. 3, 2006, U.S. application Ser. No. 11/900,757 (entitled ENDOSCOPICPLICATION DEVICE AND METHOD), filed Sep. 13, 2007, and U.S. applicationSer. No. 12/050,169 (entitled ENDOSCOPIC STAPLING DEVICES AND METHODS),filed Mar. 18, 2008.

Use of one such tool is generally illustrated in FIGS. 26A-26D andincludes drawing stomach wall tissue into a vacuum chamber of aplication head (FIG. 26A), compressing the tissue (FIG. 26B), advancingfasteners such as staples through the compressed tissue and forming acut or hole in the compressed tissue (FIG. 26C), and releasing thetissue from the plication tool, leaving the plication with a hole or cutout through the plicated tissue. In one staple arrangement, a pair ofannular staple patterns encircle the cut/hole. Anchors can besubsequently positioned within the hole/cutout as disclosed above.

Although the disclosed system has been described in the context ofimplanting a restrictor implants implantable in the stomach for limitinglimit intake of food by the patient, the systems and methods may be usedto implant other types of implants for a variety of purposes. Theseimplants include, but are not limited to obstructive gastric implantsthat obstruct flow of food into the stomach, gastric space occupiers forlimiting effective stomach volume, prosthetic valves for the treatmentof gastro-esophageal reflux disease, gastric stimulators, pH monitorsand drug eluting devices that release drugs, biologics or cells into thestomach or elsewhere in the GI tract. Such drug eluting devices mightinclude those which release leptin (a hormone which creates feelings ofsatiety), Ghrelin (a hormone which creates feelings of hunger),octreotide (which reduces Ghrelin levels and thus reduces hunger),Insulin, chemotherapeutic agents, natural biologics (e.g., growthfactor, cytokines) which aid in post surgery trauma, ulcers,lacerations, etc. Still other implants might be of a type which mightprovide a platform to which specific cell types can adhere, grow andprovide biologically-active gene products to the GI tract, and/or aplatform for radiation sources that can provide a local source ofradiation for therapeutic purposes, or provide a platform wherebydiagnostic ligands are immobilized and used to sample the GI tract forevidence of specific normal or pathological conditions, or provide ananchor point for imaging the GI tract via cameras and other imagecollecting devices. Additionally, the disclosed anchors and restrictorsare shown positioned and anchored near the gastro-esophageal junctionregion of the proximal stomach, but may be positioned and/or anchoredelsewhere in the stomach or GI system.

It should also be recognized that a number of variations of theabove-identified embodiments will be obvious to one of ordinary skill inthe art in view of the foregoing description. Accordingly, the inventionis not to be limited by those specific embodiments and methods of thepresent invention shown and described herein. Rather, the scope of theinvention is to be defined by the following claims and theirequivalents.

Any and all patents and patent applications referred to herein,including for purposes of priority, are incorporated herein by reference

It is claimed:
 1. A medical implant system for use in the stomach of apatient, comprising an intraoral plication device for forming in thepatient's stomach, by intraoral access, a tissue plication having anopening surrounded by a plurality of staples, an anchor having a base,an elastically deformable head, and a stem connecting the base and head,said base and said head in its undeformed state having dimensions largerthan that of the plication opening formed by said device, allowing theanchor to be attached to said plication, with the anchor stem extendingthrough said opening, by pulling the anchor head in a deformed statethrough said opening, and a grasper tool adapted, with said anchordelivered into a patient's stomach adjacent said plication to: (i) bemanipulated through said plication opening, (ii) grasp the anchor head,(iii) pull the anchor head through said opening, by deforming the anchorhead, thereby to attach the anchor to the tissue plication, and (iv)detach from the anchor.
 2. The medical implant system of claim 1,wherein said anchor head includes an elastically deformable ring andstruts connecting the ring to the stem, and said grasper tool engagessaid ring as it pulls the anchor head through said opening.
 3. Themedical implant system of claim 1, wherein said anchor head includes anelastically deformable ring, struts connecting the ring to the stem, anda loop connected to said ring, and said grasper tool engages one of saidring or loop as it pulls the anchor head through said opening.
 4. Themedical implant system of claim 3, wherein said anchor head, stem, andbase are molded from a compliant silicone.
 5. The medical implant ifclaim 4, wherein said head is molded from a higher durometer silicon,and said stem and base, from a lower durometer silicone.
 6. The medicalimplant system of claim 1 wherein said grasper tool includes a grasperthat can be closed and opened from outside the patient's body to engageand release the anchor head, respectively.
 7. The medical implant systemof claim 1, which further includes a handoff tool for delivering theanchor in the stomach, said handoff tool having an open constrictionadapted to engage an anchor stem and release the anchor after engagementby the anchor head and pulling the anchor away from the handoff tool. 8.The medical implant system of claim 1 which further including aplurality of said anchors, for attachment to a plurality of such tissueplications in the stomach of a patient.
 9. The medical implant system ofclaim 8, wherein said plication device and grasper are adapted forforming and attaching an anchor to each of a plurality of tissueplication arranged about the gastroesophageal junction in the stomach ofa patient.
 10. The medical implant system of claim 9, which furtherincludes a food restrictor having a plurality of anchor openings bywhich the restrictor can be attached to said anchors arranged about thegastroesophageal junction in the stomach.